 So it's 1202. I'm going to let Mark take it over. All right. Well, welcome, everybody, to this session of our annual lecture series on the history of medicine and ethics. Let me just remind you that this is the last session of this year, that the next two weeks will be taking off because of the holiday season. And when we resume, I'm afraid to tell you, it will be on Wednesday, January 5. And sadly enough, I'll be giving the talk on that day, so on January 5. But today I'm really excited with our final speaker of the fall quarter. It's Dr. Lydia Dugdale. Lydia Dugdale is the Dorothy L. and Daniel H. Silberberg associate professor of medicine at Columbia University, Vagalos College of Physicians and Surgeons, and the director of the Center for Clinical Medical Ethics there at Columbia. Lydia also serves as the associate director of clinical ethics at the New York Presbyterian Hospital at Columbia University Medical Center. As a practicing internist, Dr. Dugdale moved to Columbia in 2019 from Yale, where she had worked for a decade or so in a very active, high volume, primary care practice after she had completed her internship and residency at the Yale New Haven Hospital. While at Yale, Lydia obtained a master in ethics from the Yale Divinity School and served also as the associate director of the program for biomedical ethics at Yale. Lydia and I know each other from her years as a medical student here at the Pritzker School of Medicine where she and I met. She gives me credit for inspiring her to pursue a career in medical ethics, but I think that that is Lydia's plan and intention. Since she left Chicago more than 10 years ago, Lydia has made it a priority to attend the annual McLean Fellows Conference whenever it's possible for her to do so. Lydia's scholarship focuses on end-of-life issues, medical ethics, the doctor-patient relationship. She edited an academic collection of essays entitled Dying in the 21st Century by MIT Press back in 2015 and is the author of a book called The Lost Art of Dying published by Harper in 2020, which is a very popular press book on the preparation for death and dying. So with this background, I am just honored to introduce you to Dr. Lydia Dougdale, who will speak today on The Lost Art of Dying. Lydia, welcome, please. Thank you, Mark. And thank you, Mindy, for the kind invitation. It's so great to be here. I'm just looking at the list of participants. I see many names of really my former professors. So it's a delight to be with you. And Dr. Meredith, I see you here. I hope I don't bore you. I think you've heard some partial version of part of it before. So great. Let's dive right in. I'll just let me move your faces. OK, so we'll come back to this painting. But I'm going to just tease you with this wonderful with a crop of this wonderful painting by Heronimus Bosch, and we'll dip into it a little bit later. I only have book royalties, which are not that substantial. So that's it for disclosures. This is where I think we'll go today. I'd like to talk about this phenomenon of dying poorly, certainly with Omicron upon us, as some of us were chit chatting before the call. And in light of the last year and a half, death has certainly been part of the public imagination, although probably partisan debates over masking and vaccines have been more a part of the conversation. But this question of how we die and whether we die well is where I'd like to start. And then follow that with this question of what it might mean to die with more preparation. And then I'm going to be talking in that part of the talk about a model for preparing for death known as the Ars Moriendi, which is Latin for the Art of Dying. And then the third part of the talk I'm going to ask really, which is the question I've been asking for the last dozen years or so, is it possible to revive this Ars Moriendi or this Art of Dying? So what do we mean by dying poorly? I'm starting with a case because good medical lecturers always start with cases. And this is a gentleman that I took care of back in Newhaven. I used his story to open up the book. And he is an individual that I met actually as a corpse before I met him as a man. He was dead. And I was a part of the code team. It was the middle of the night. And the code blue went off overhead, calling us to the cancer ward. And of course, everyone who's been on the code team will know that when you are summoned to the cancer ward in the middle of the night, there's always accompanied invariably by a sense of dread, I suppose. And sure enough, he was the classic appearance of someone that we dread resuscitating. He was very elderly, had a longstanding history of prostate cancer. He had actually been treated appropriately. And his cancer was years earlier. It was in remission. And he had been doing very well. But a couple of weeks prior to admission, he had started complaining of increased bony pain and demonstrating confusion to his adult daughters. And they became concerned, brought him in. And the stands revealed that, in fact, he had metastatic disease to his brain and throughout his bones. He ended up having a cardiac arrest the night that I was on the code team. We successfully resuscitated him. I didn't know his family. I didn't know him. I got the one-liner or two-liner from the intern. But I felt that someone needed to sit down with the family and make sure that they understood just how sick he was and also how concerned we were that he would, in fact, arrest again, that his heart would stop again. And so no one else wanted to. No one else really knew the family that was in the hospital that night, apart from the intern. So I sat down with the daughters and tried to list what they understood about his situation. And they were very firm. They're quite devout in their faith. And they felt very strongly that a miracle is always possible while there's life. There is hope. And they wanted us to resuscitate him should his heart stop again. Within an hour and a half or two hours, the code blue was sounded again. This time we went running to the ICU where he was. And he had, in fact, had a second cardiac arrest. We successfully resuscitated him again. And he died a third time that night. But that third time, our CPR was unsuccessful. So this case, which happened quite a while ago, has stuck with me. It really affected me as a resident. And it kind of haunted me over time. And it got me wondering, why don't we do a better job thinking about our mortality? Were we to think about our mortality in advance? Could we mitigate some aspects of highly medicalized dying? And what else in what other ways would we benefit from the preparation for death? So these are the kind of questions that I was puzzling about really actually from the time of medical school and spending time in the ICU. So what do we mean by dying poorly? It's sort of a very superficial way to think about it is that most people say they want to die at home. The Kaiser Family Foundation in their poll says that 71% of people want to die at home. When the Journal of Piety of Care published this paper by Higgins, Higginson that they interviewed patients with advanced cancer. Now, keeping in mind, patients with advanced cancer are spending, often spending quite a lot of time in health care institutions and have a strong sense of what it means to die in the hospital. More than half of them still say they want to die at home. But what we know is that most people actually die in institutions. So this was a research letter, I believe, or perhaps even just a letter, I think a research letter that was published in the New England Journal in 2019, but it made national headlines. I was picked up by all the newspapers because it was the first time that home deaths surpassed hospital deaths. So what we're doing in this graph is comparing 2003 with 2017. And you can see that in 2003, those who died at home were approximately 24%. By 2017, it was 31% of people. So about a third of people dying at home. During that same period, hospital deaths decreased from 40% to 30%. So the difference is minimal, really. Just 1% more dying at home than in hospitals. But if we are to add other institutional deaths to this, we see that nursing facility deaths in 2017 are still at about 21%. And hospice facility deaths increased from about zero in 2003 to 8.3% in 2017. So if you take together these institutional examples of dying, it's about 60% of people who are dying in institutions. Now, incidentally, that gray line there marked as other, in the letter, they don't actually specify what that refers to. So I can't tell you if that refers to more institutional deaths or not. We just don't know. Then there's this other question. Again, perhaps rather superficial, especially in light of more recent studies, but is dying well associated with not having an advanced directive? If, for example, even though there's a great study, great paper recently, I believe in JAMA by Morrison and colleagues saying that advanced directives essentially don't do the work we want them to do. But even if we were to say advanced directives are a surrogate for having conversations about the degree to which one wants to interact with healthcare toward the end of one's life, then we can say, well, this at least lets us know if people are talking about it. In fact, Health Affairs reports that only about a third of people, 37% of people, in a study combining more than 795,000 people, only about a third actually have advanced directives. And it's noteworthy that in this current moment when we, especially post George Floyd, when worldwide we've been wanting to make sure we are attending carefully to groups that might historically have been marginalized, we can see that when it comes to non-Hispanic blacks and Hispanics, very, very few have advanced directives. And the reasons for this obviously are many. We could certainly talk about it in the Q&A. But again, this could be a surrogate for the fact that individuals are not engaging with their clinicians in conversations about the degree to which they want to engage with healthcare at the end of their lives. And then there's this study, which of course is very famous and you probably don't need me to talk about it, but I'll just say the one liner on this is that Harvard Hospital enrolled patients with non-small cell lung cancer in two different tracks. There was the possibility of having early palliative care from the time of diagnosis of cancer versus having standard of care, which is essentially you get palliative involved as and when you need them involved. And what this study found out, the reason why this study made headlines everywhere is that the patients who had palliative care from the time of diagnosis actually reported higher quality of life, less depression. They used less chemotherapy and they lived almost three months longer than those patients who had only the standard of care with palliative. So again, is this what we mean by dying well versus dying poorly? Is dying poorly standard of care with regard to palliative care? Or is it dying well, having early palliative care? Is this what we mean? And so all of these questions are on the table. Now I'm gonna talk for a minute about this painting by Bosch because this painting highlights and paintings like it highlight this phenomenon that was particularly popular in the late Middle Ages of thinking about one's mortality even while one is healthy. These paintings were meant to provoke the viewer to think about their finitude, about their finiteness. So what do we see? Again, this is a cropped image. This painting is called Death in the Miser. Art historians think, and I'm not an art historian so if anyone is, you can feel free to correct me. I won't take offense at all. But art historians think that the gentleman in the foreground in the sort of greenish brown robe leaning over the proverbial treasure chest is in fact the miser when he was a younger man. You can see that he's got on a nice robe. He has a key around his waist which is presumably the key to this chest. And in this chest, there is a bag of money. Now the painter Bosch would want you to know that this money is not morally neutral. The money actually has an ethic attached to it. And it's an ethics that's concerning because this money has a grip on the miser's life. We think that the man in bed, the rather frail and pale man is the miser late in life. And now he's dying. And if you could see the full painting, you would see that the angel who was accompanying him is desperately trying to direct his gaze up to the window where if you saw the whole painting, you would see a crucifix. So the angel is saying, you need to figure out your religious questions, but the miser is not having any of it, right? The miser's gaze is fixed directly at the door where death itself is coming in and death is holding an arrow aimed at the miser's heart. The miser's right hand is extended down to a bag of money, which suggests that even in his dying, this gentleman is captivated by his material possessions. And Bosch would want you to realize that this is keeping him from dying well, that his obsession with his material goods is keeping him from doing the work of preparing to die well. This is just with regard to greed and money and wealth, but there were many different paintings of this genre that would try to highlight different aspects of different vices, if you will, that would keep people tied to this mortal life and prevent them from doing the work of preparing for death. I'm just gonna make one other comment about this painting. And that is, recently I was speaking on this painting and someone in the Q and A raised the question, actually it was a rabbi who raised the question of whether this painting was in fact, supposed to be targeting Jewish people. And I raised that because I went back and tried to do more digging on it. And I haven't found anything that makes that point conclusively. The rabbi raised this question because there was a caricature in the late middle ages that associated, obviously it was a terrible caricature, but that associated Jewish individuals with wealth and greed. I feel comfortable using this painting in this talk and continuing to talk about it because I have found nothing that is conclusive on that point or offensive, but I wanted to bring that up because this rabbi recently raised that issue to me. So that's just a side note. That's all I'll say about that. Okay. So we're sort of now immersing ourselves, going back, trying to get into this mindset of a period in history when people felt that it was very important to think about one's mortality and to prepare for death. And what triggered that was the bubonic plague outbreak of the 1350s? So this is the second case. And I'm gonna present this case as a contrast in a sense to the gentleman I cared for in New Haven years ago to highlight how disease and our response to disease can distract or help us think about our mortality. So this excerpt here is a piece written by Giovanni Boccaccio. Boccaccio was an Italian humanist and something of a philosopher. He was a writer. He was basically a really wealthy man who didn't have to work for a living but could pass the days sort of an intellectual company and writing. And that's what he did. The interesting thing about Boccaccio is that he lived in Florence during this outbreak of plague that struck Western Europe in the mid 14th century. And he survived. He survived that plague outbreak despite its massive death toll. And he wrote a book called The Decameron. I'm sure some of you who have a rich humanities background have heard of The Decameron. The Decameron is actually a set of 10 stories that friends told themselves while staying at a countryside villa to pass the time during the bubonic plague outbreak. So the stories themselves are fiction but the introduction to The Decameron which is written by Boccaccio tells us what it was like in Florence during that period. And this was Boccaccio's description before he got out of Dodge, right? And so he says, look, there appeared certain swellings either on the groin or under the armpits where some waxed up the bigness of an apple or an egg. And these were essentially plague boils. And time these turned into black or livid blotches people would develop gangrene was one of the manifestations of plague. And that's what he's describing. The swellings in the groin and armpits was actually lymph adenopathy, profound enlargement of the lymph nodes. I'm showing you this etching done by an Italian artist, Luigi Savatelli. We think in the early 1800s but I'm showing you this etching because it characterizes what it might've been like in Florence during that period when Boccaccio lived. And he was attempting to describe the outbreak of bubonic plague. For those of you who read Italian you can see that it says at the bottom the plague of Florence as described by Boccaccio. And so what do we see here? Well, most notably perhaps we see a massive pile of dead bodies in the front center slightly to the right of this image. In the background there are a group of hooded men with pickaxes presumably waiting to hire themselves out to bury the dead. And in fact, Boccaccio describes that for us. He describes a group of men from what he called the baser ranks of society who saw this outbreak of plague as a unique opportunity to make a fast dollar or whatever, lira, I don't know what they had back then. And so these men would hire themselves out to bury the dead. But just as during the first COVID outbreak certainly in New York city where I live it was impossible to keep up with burying the dead. And even in New York city on Heart Island we have our own mass graves from COVID victims for unclaimed bodies or those whose families were unable to afford to bury them. So this phenomenon is certainly real during pandemic. You also see in the background it looks like maybe a priest is waving some incense. And then in the foreground, there's a group of well-dressed men and I will credit Dr. Stephen Meredith for pointing out that Boccaccio here, this is Boccaccio himself, Sabatilli put him in the etching as the one who gave us this history. Boccaccio may be holding a copy of Dante's Inferno according to Dr. Meredith. I'm also wondering if he's not holding a copy of the Decameron, but I don't have an answer for that for you. So bubonic plague was called bubonic because of these swellings of in the groin. The Greek word actually we have Constantine on the call, so I am told as not being a Greek scholar either that the Greek word for groin is bubos. And because the swellings in the groin were so prominent with bubonic plague, it took on that name. But it was also called the Black Death and these names are used interchangeably and it was called the Black Death because one manifestation of it, there was also a pulmonary manifestation, but one manifestation was that the tips of the fingers, the toes, the lips and the nose would become gangrenous, the tissue would auto amputate and fall off. Now the doctors of the era did not know what caused plague. Of course, now we know it's caused by the bacterium, your syniapestis, but no one had any idea what caused plague then. And so to try to thwart or to mitigate contact with this dreaded disease, the doctors would dress head to toe. The mask that the doctor wore certainly looks bird-like. That was intentional. From my read of the descriptions, this served two purposes. One is that the mask was meant to evoke the image of an Egyptian divinity that would thwart illness and death and scare away the evil spirits that might be causing disease. The more functional reason for the beak was to stuff it with herbs and spices so that as the doctor approached the patient who had these sort of open lesions and gangrenous appendages, the smell might be quite overpowering and he could mask the smell by breathing in and out through the herbs and spices stuffed in the beak. The eyes were covered with glass. The doctor wore a long waxed raincoat with trousers underneath gloves and a hat. In a sense, the attempt was to try to cover everything possible because they did not know what caused the disease. Historians vary in their estimates as to how many people died, but there is a figure that the highest figure is that perhaps as many as two thirds of Western Europeans died. The lowest figure is around 30%, but whether one out of three or two out of three were dead from this episode of bubonic plague, it was devastating. There's no question. It absolutely ravaged society. And this episode of plague lasted several years, not until similar to COVID and it started closer to Eastern Europe and moved westward all the way to the present day UK. Now, if you think about doctors dressing this way, here is a physician from the early days of COVID. Also, I mean, if you guys think back to what it was like at that time, I was doing frontline COVID work here with the first wave in New York City. And we really, we covered everything. We had no idea. I mean, we had no idea how it was being spread. Should we cover our hair? Should we cover our ears? And we sort of tried to cover up as much as possible to keep from taking the virus home. And here, this is just for fun. This is Halloween in New York City. I was walking down West 90th Street and this guy stepped out of his brownstone and he made himself the plague doctor costume for Halloween. Anyway, I had to take a picture of it. So the question then is how might we prepare for death? And in response to this mid 1300s outbreak of bubonic plague and one to two thirds of Western Europeans succumbing, there was a real sense among survivors and that they needed to know how to do this preparation for death stuff themselves. Why is that? Well, if you think back to Western Europe in the late middle ages, it was most of Western Europe was under a single social authority. And I'm saying social authority here, but the people who really exerted kind of a certain power over life and death was the Western church. Now, I fully recognize that there were non-religious, non-Christian people living in Western Europe at the time, but by and large, the leading social authority was the Western church. So for most people living in Western Europe, there was a real concern during this outbreak of plague that their loved ones and everyone lost someone might be damned or worse, might have some sort of fallout from having been inadequately buried, not receiving last rights, not having a funeral. You name it, right? There's a lot of fear. This was a time when large swaths of the population were illiterate or semi-literate. This was not a time of empowering the people to do this work themselves. There was a lot of concern that death would come back if it wasn't plague, maybe another round of plague, another wave, but it might also be famine. It might be war, but death would come again. And the sort of popular cry was that they wanted to be equipped. The lady, most of the population in Western Europe at this time also felt, many of them felt abandoned by their leaders because the people who were well-connected in positions of authority, including some clergy, also skipped town. If you were well-connected and could get yourself to a countryside villa where the air was clean, right again, they don't know what's causing it, you'd be better off. Of course, now we know that plague is carried by a combination of rats and fleas, and it was really the migration of rats that spread the illness. But if you had the option of going to a countryside villa where there were no rats that were infected with plague, you could probably make it quite well. So there's this cry on the part of the people, give us the tools to prepare for death. They're asking this of their sort of parish leaders. Now, I'm no church historian, but from what I understand, the Western church at this time was suffering from a political crisis. There were two men and then later three men simultaneously claiming to be Pope. So the church was in no position at all to respond to the needs of the people. And this really would have been priests or clergy is the intermediaries between life and death. It really would have been their job. So what happens is finally the church pulls itself together and they organize to respond to the laity. And one of the first orders of business was to write up a handbook on the preparation for death. Now, as you might imagine this first iteration with its affiliation with the church would have had religious content as well as practical content. But that was the idea of this very first handbook known as the Ars Moriendi. By 1450, and this is the image I show here, they developed an illustrated version. So the oldest text based version we have is probably about 1415. And then there was, thereafter developed an illustrated version. The idea being that even the illiterate or the semi-literate could study the images, understand what they meant and do the tasks of preparing for death. Just to give you a sense, this is also from the 1450 illustrated version, but what these would have shown, for example, to the illiterate or the semi-literate, they would have said, look, one of the tasks of preparing well for death is to exercise patience. And in fact, if you want to die not angry and sort of thrashing against the universe, but to die sort of calm and collected and with patience, you have to exercise patience over the course of your lifetime. So they would contrast these images. And in fact, the illustrated version paired five, you might call them vices with the five virtues that they were commended to exercise over a lifetime. So in this image on the left, you see the dying man. He just wants to go on and get it over with. Maybe if euthanasia were an option at that point, he would have asked for it. He is sick of the suffering. He's turned over his table. The bowl and spoon are on the floor. He's kicking away the doctor. There's a woman in the background. We think might be his wife. And the scroll says, see how he suffers in Latin. That's kind of like a comment bubble and a cartoon strip. And what they would have wanted the viewer to know is that this is not a morally neutral angry man. There's actually a cosmic war for the guy's soul. And you can see that by this little devil under the bed or demon or whatever winged creepy thing. And the comment bubble coming from this winged creature says, look how I have deceived him. So this image would have told, you know, the viewer in the late middle ages, one of the things you need to do to die well is to exercise patience. You don't wanna die like this guy. You know, the devil or the evil creatures want you to die this way, but there is a better way to die. And so this image was always paired then with this consolation, image of consolation or comfort through patience. And here you see the same dying guy. He's much calmer now. He's lying in bed. He's being attended to by Christ and God the Father and an angel. There still are some kind of evil looking creatures lurking about, but they seem much more powerless. They don't exert the same kind of authority that the guy with wings in the left does. And then there are these four characters at the foot of the bed. And these four characters, the viewer, again, I don't know this stuff. And probably most of you on this call don't know this stuff, but in the late middle ages, if you were illiterate, you would know the images. You would know the characters that these images represented. And so we see, and I have to look this up always, but the man holding the stones at the foot of the bed is Stephen, a first century martyr who was stoned to death. And likewise, Catherine, I think it was Catherine or Barbara beheaded in the tower. Lawrence was burned to death on the gridiron, et cetera. So these are martyrs who demonstrate to the dying person that we have a heritage, right? This would be the narrative. We have a heritage of people who have suffered, for whom dying has been difficult, but they have been victorious. They have exercised patience, and their dying has not been in vain. Okay, again, this is just the sort of idea that this very first iteration of the Ars Moriendi sought to kind of provoke in the viewer. So if today we think in ethics, we have a very basic view of ethics as principalism, which I'm not advocating, but I'm just saying bioethics, most distilled, autonomy, justice, beneficence, non-milificence. If you ask an ethicist today, what does it mean to die well? And what can ethics contribute? It might be something, some version of trying to do this. Well, in the late Middle Ages, it would have been practicing virtue ethics. So to die well is to die courageously, or to die with patience, or to die with humility, or to die in a spirit of generosity, or with a spirit of hope. These were the kind of attributes, the kind of character traits that one could practice, to which one could habituate oneself, so that you're not only courageous and patient and humbled through your life, but you're manifesting these and really leaving a legacy of these sorts of traits at the end of your life. Now, this first handbook from the Ars Moriendi, which has early ties to the Western church, did not stay within the Western church. So this is, you know, 14, 15 was the first version. This is pre-reformation, which means it's like, even before there's Catholics and Protestants. So then 100 years later, you get Protestants and Catholics. There were then spin-off Protestant versions by the 1800s in Drew Faust's book, This Republic of Suffering. We know that there were Jewish practices related to the Ars Moriendi, and even straight-up non-religious, full-on secular practices. She says in this book that by the time of the Civil War, whether you were from the North or the South, whether you were religious or not, practicing the Ars Moriendi, that is practicing the art of dying was just part of living well. Because if you want to die well, you can't save that work up until the end. And as these young soldiers in the war knew very well, death was always possible. Death could come at any time. And so the work of preparing for death really starts now. It starts today for everyone, and it continues throughout a lifetime. So this book actually, if you're interested in this, is such a fantastic read about death and really how the Civil War in America particularly changed our practices of death and dying. So there were all these versions of the Ars Moriendi. They circulated throughout the Western world. They were translated into many languages. They were adapted and adopted by many different cultures. And they remained in widespread circulation until interestingly the end of World War I. And given where we're at right now with coronavirus, I'll just say a couple of things about the second bullet point in particular. If you think back to where we were with World War I, World War I was devastating to the world not only because of the number of soldiers who died, but also because of the number of civilians who died. Millions and millions and millions of people died around the world during these four, five year period. Even before World War I ended, there was an outbreak of the influenza pandemic of 1918 to 1920, which epidemiologists think also came in four large waves and lasted for the better part of two years. In contrast to most seasonal flu epidemics or even season bouts of seasonal flu, the pandemic of 1918 to 1920 affected young adults, healthy people. There are autopsy reports of young soldiers from the front lines whose lungs were described as just being like wet sponges, just full of the inflammatory cells and the virus caused by flu. So what that means is that back to back between World War I and the flu influenza pandemic of 1918 to 1920, we have six years of unremitting sustained death worldwide. People were sick of thinking about death. And in the United States at least, not everywhere in the world, but in the United States at least post World War I and post flu pandemic, we moved into a period of enormous economic prosperity. We had radical building boom in the 1920s. Women got the right to vote. There were radical changes in fashion, short skirts, bobbed hair. There were new forms of dance. Many more people got automobiles. And we also have in the 1920s the birth of antibiotics. So 1920s birth of antibiotics and things just take off from there. By the 1940s, we have chemotherapy. By the 50s and 60s, we're working at early attempts at cardiac resuscitation and organ transplantation, mechanical ventilators. By the 1970s, we have combination chemotherapy. And really what medicine has done is made death optional. And as all of you know, we are expert now at maintaining the vital functions of otherwise dying patients in the intensive care unit at length. So this combination of the world being sick of death, juxtaposed with prosperity and a takeoff of medical innovation conspired to kind of, you know, beat the life out of the arse Moriandias that were, right? The arse Moriandia really fell from popularity where it had been wildly popular for more than 500 years and recognized as necessary both to living and to dying well. And there were other trends too. Industrialization meant the move out of large family homes in the countryside to urban centers where there were more factory jobs but living in crowded flats or tenements even if you were making money to send it back home. It also meant that there wasn't space or personality care for the sick. So we also see a concomitant rise in the hospital. I have the numbers in my book but I think it's something like in that around the time of the Civil War just after there were a few hundred hospitals and by the 1920s there were more than 6,000 hospitals in the United States. I think I have those numbers correct. Suffice it to say the hospital now became an acceptable destination for care of the sick and dying. And certainly with hospitals also offering things like antibiotics, why wouldn't you go to the hospital before you die? And so there's a giant shift then in who cared for the sick? And then there's this other piece of secularization this is just maybe interesting for some people on the call but if you read the text of clergy's sermons or homilies during the time, it was a common topic of discussion in religious settings to talk about the preparation for death before World War I. And by the time the war was over and the flu was over, no one wanted to talk about the preparation for death anymore in religious context. So all of these things kind of conspired to make the Ars Moriendi go away. So the question then in my mind has been this can we revive the art of dying? You know, this patient that I started to talk with and many other patients have got me thinking about this. And one of the things that I like about the Ars Moriendi when I first discovered it maybe more than a dozen years ago I was struck that, yes, it started within you know, a particular religious context but it didn't stay there. It actually was adopted and adapted by all these different cultures and religious and non-religious groups. In a sense, people recognized universally that mortality is 100% and that all of us need some sort of handbook to prepare for death. All of us need some sort of way to navigate these big questions of living and meaning and what happens when we die, all of those questions. And we have specific communities at least we had specific communities in which we could wrestle with those questions. And so there were all of these iterations and I loved that idea when I first read about the Ars Moriendi, I thought, this is great because if my own colleagues and I've had fellow physicians tell me they go to great lengths not to tell their patients when they're dying because my colleagues themselves are so afraid to talk about death that they don't wanna go there with their patients. If we as medical professionals are going to fail our patients, if we're going to be uncomfortable giving bad news, if we're going to emphasize improvements in kidney function when the whole ship is sinking as it were, then we need to make sure our patients are empowered. I loved that idea of patient empowerment and that's partly what led me to start thinking about could we revive this Ars Moriendi, could we revive this art of dying? So here's how I thought about it. Again, this is slightly embarrassing if you studied philosophy, but just go with me here. I'm thinking about how premises lead to conclusions. So I started thinking, okay, we don't die well, previous generations died well, we are not, I mean, to really have the, be a perfect syllogism that we would need to say, we are not previous generations, but just go with me. We'll say we're not like previous generations. But then I'm thinking, well, could we learn from them? I mean, yes, society is so different than it was in the late middle ages, more complex, more diverse, but could we learn something from this idea of adapting a handbook to our own cultural context? And then I was thinking about this, well, medicalized dying occurs in plural institutions, pluralistic institutions. We have all different kinds of places where people die. Plural institutions look to the language of bioethics, of clinical ethics, of medical ethics to provide the common moral language and structure for resolving conflicts. I'm including all of those different kinds of ethics because some hospitals are run by PhD bioethicists and other hospitals like yours and mine are run by a physician clinical ethicist. But suffice it to say, it's really ethics more than religion, right? That gives the moral language and structure for resolving these deep issues in modern medicine. So then I thought, well, maybe ethics can solve the problem of medicalized dying. At least that was the initial pitch. And so I wrote a piece for Hastings Center Report a long time ago, they published it and then I was asked to do a book that took me a few years to get done, but did that. And this is edited as Dr. Siegler said, and at the time, actually when we were working on it, we presented all the authors converged in Chicago and Hyde Park. And we presented the different themes to try to think about what would this framework look like in a pluralistic culture, all these different hospitals, how could ethics do this work? So anyway, this is highly academic. And this is the sort of, if we were to break that book down into one slide, medical ethics can improve dying. It can provide a framework for the reinvigoration of the R's more handy if it can foster. And I sort of suggest these two things. If you're going to dumb down the art of dying to its two most basic principles, it's that we need to foster a clear recognition of finitude, right? We can't talk about preparing for death if we don't want to think about death. And certainly I've had patients, very few, but who have not been willing to talk at all about their mortality. It's as though they think they will never die and that to me is incredible. But if we're going to do this work of preparing for death, then we need to be able to talk about our finitude. And then the other piece that I think is critical to any discussion of the R's more handy is that it always happened. The art of dying well always happened historically within the context of community. And I believe that community is necessary to revive the art of dying for the 21st century. But then the question is, can ethics do enough to help patients? And so we did that first book and I was dissatisfied with it from the standpoint of it didn't seem, it certainly wasn't accessible for patients. It was very academic, it was very theoretical. And it wasn't something I could hand my patients. And I wanted a book that I could hand my patients and say, look, I really care about how you die. And I really care about how you live. And those are very, very connected, right? If you want to die while you've got to live well. And how could I put this tool in their hands? So I wrote this second book and this is really super user friendly, full of stories and art and poetry and a little philosophy. It's just great fun. But I wrote this book really to try to empower my patients. So if I were to summarize that book in three bullet points, it would be this, Health, Home, and Hope. I maintain that if we want to cultivate this art of dying then we need to talk about the very specific practical stuff related to health related to medicalized dying related to the hospital. Maybe it's advanced directives but maybe it's just that ongoing conversation and that ongoing conversation that you encourage your patients to have with their family members. I, last year, I think it was last year I published an article in stat news on Black Friday and how Black Friday should be the day that we have conversations with our loved ones about what our end of life wishes might be. Why Black Friday? Because Thanksgiving's a day of feasting and being with those you love. And Friday is supposedly the shopping day where you remake yourself and you think about what it means to live well. So I thought, well, go shop and think about what it means to live well. And then come home in the evening and think about what it means to die well. I mean, there's no reason why we can't have those conversations. But the very practical stuff, I think it's also very important for our patients to be able to engage their doctors on this question like Dr. Siegler and Dr. Schwartz. I'm a primary care doctor. I still see patients. I love seeing patients. And these are conversations that Medicare wants me to have with my patients every year. And I do, and it has to be a part of even how we develop our relationship and openness to be able to talk about these questions. I wondered for a long time, what is the, how can I give patients advice about when are they too old, right? There's always this question of, oh, is grandma too old for this procedure, that procedure? And I talk about this toward the end of the book. It's not really, there's not really an age cutoff. But some of the frailty risk scores that are circulating right now are quite good and quite effective at helping us get a sense of how frail our patients are or are not. And whether a particular intervention may or may not have a favorable outcome based on their degree of frailty. I think this is really helpful for helping families and patients navigate end of life, the medicalization of the end of life. And then there are these questions of home, right? Community is central. It's foundational to the art of dying. It might not be blood relatives, right? We recognize that there are all different kinds of communities, all different kinds of relationships and networks. Sometimes people ask me, they say, oh, I'm kind of a loner. I don't have much of a community. I think to live well as to die well, you need somebody. It doesn't have to be a huge team, but you need somebody. And so nurturing those relationships now will lead to better relationships toward the end of your life. Once a guy asked me, he said, look, I know who I want to be at my death bed, but frankly, I can't stand the guy. Is it OK if I just wait to work on my relationship until I get a terminal diagnosis? And we laughed because, of course, that's ridiculous. Again, none of us knows how many days we have. None of us knows when death will come, when death is going to be knocking at the door aiming that arrow at our heart. And so it makes sense to invest in those relationships now, to reconcile as appropriate. Not in a Pollyanna-ish way, but in doing the hard work of really building a relationship. And then I have a whole chapter on ritual. I think ritual is fascinating the way rituals have developed over time in different cultures. But really what ritual does is, especially the ritual, I mean, we all are kind of inventing rituals these days, but the rituals that are kind of tried and tested over time develop as a roadmap for communities when everything is chaotic. And if death is anything, it's chaotic. It creates total chaos. And so rituals help us navigate that chaos. I will say that I don't do in any sense an exhaustive review of what every culture does to navigate death. That book has actually been written by Howard Spiro. However, I highlight a few different rituals just to get people thinking. There's some really beautiful ones. And I just kind of highlight the things that struck my imagination and put it out there for the reader to ponder. And then there's this question of hope, right? And this gets back to these big questions. What matters to me? Why am I here? What does it mean to be on earth? What happens when I die? And these are questions, again, that tomes have been written about, right? Why is men and women forever have discussed them, have passed on understanding and interpretation? I don't think in any sense of the imagination, we need to reinvent this sort of genre of literature. But all of us could probably stand to do some reading and discussing answers to these questions within the context of our community. So with that, I will stop and see if there are any questions. Thank you so much. Thank you, Lydia. That was terrific and tremendous food for thought. I'm going to open it up to the conversation for a minute, but there were two things in the chat that I just wanted to think about before you go, OK? One of them was Stacey Levine, who's the head of geriatrics and palliative care, said, what can ethics do to help clinicians accept and discuss finitude with their patients? And you may want to do this at the end. And the other one was Emily Sutherton said, could you explain a little more, is comfort care and or palliative care an example of virtue ethics or principalism? Those are just two thought, there's a lot of comments in the chat, but I thought those were two very good questions and things you might just want to just address for an issue before we open up the floor. Yeah, so thank you for those questions. So I'll start with the first one. What can ethics do to help clinicians? I think it is understand finitude or maybe talk more openly about finitude with patients. So the preamble to my answer is, well, of course, it depends on how big ethics is, how small the hospital is, how well it's funded, and what kind of resources are available. So I'll just say that during the first COVID wave here, we ended up working with Hospice and Palliative Medicine, our palliative care group, to train large numbers of trainees, retrain, mostly psychiatrists, in how to have conversations about end-of-life wishes, living and dying well, and deployed teams of psychiatry trainees to the emergency department to have these conversations with patients. That wasn't ethics driven, that was palliative care driven, that we worked very closely together. Something like that could be a model. Again, you need a team of people. And the first wave of the pandemic made it possible to have a captive audience in the emergency room, unfortunately, to have these conversations. The other thing that I'll just share is that I've been asked by my hospital, actually, to design a curriculum which would be required training for everyone on the wards, so both attendings and residents that would get at some of these issues. So I actually have a conversation with the COO tomorrow morning. But that would be another model. So it's so easy to do these training modules now. And I don't mean the ones that you kind of, the HIPAA ones where you just fast forward through all the slides. I don't know if any of you know what I'm talking about. But I'm talking about one where you do it face to face. You can do it face to face on Zoom, but say a three-hour module where we are, prior to going on the wards, everyone is required to have a training about how to talk with patients about a series of issues. And so my suggestion to the hospital is that we look at, well, I've already looked at what are the big issues that clinical ethics deals with. Obviously, end of life care is one of those. Questions of finitude is one of those. And then through case-based presentation and discussion, we can help train. And if everyone's required to do this training every year, my guess is there would be a multiplier effect where people would become more and more comfortable having these conversations. So that would be another idea. If it's successful here, I'll let you know. Then there's this question of whether hospice and palliative medicine, if I understand it, is more like virtue ethics or more like principalism. And I'll say this. So in the book that's the collection of essays, the academic book, Farr Curlin, who used to be with you all at the University of Chicago, has a chapter on hospice and palliative medicine. And he talks about how the good work of dying well has been, I'm totally putting words in his mouth at this point, because I haven't read the chapter in many years, but has been threatened, in a sense, by the drive to be able to measure and assess and accredit hospice and palliative medicine programs. So when we take something that is a good, that is very human and very organic, in a sense, sitting with a dying person cannot be more simultaneously uncomfortable and beautiful and complex and emotional and spiritual. It's like all of these things. But when we try to turn that into something that we can assess and measure and say you're doing a good job or not doing a good job, then it loses some of its authenticity and maybe some of its genuineness, some of its rawness. And so maybe, OK, so that's his critique, if I can summarize it poorly. So then the question becomes, is it the discipline that practices the ethics, whether they're virtue, ethics, or principalism, or is it the individual practitioner? And I would suggest that on the whole, I've had wonderful, wonderful experiences with my colleagues in hospice and palliative medicine. But I'm sure that there are individuals within that discipline who are more or less ethically attuned. And by that, I mean that there are probably people who see themselves as filling this perfunctory role of responding to symptoms and checking boxes. And then there are others who are working harder to really develop and hone and cultivate the virtues that are required to care well and genuinely and intimately for dying patients. I might be totally wrong on this. I'm kind of trying to think about it in real time. But all this is to say, I don't think it's the discipline. I think it's the individual. On the whole, I have loved my colleagues in hospice and palliative medicine. I do think they're exhibiting virtue ethics, actually, practicing virtue ethics. But I'm sure there are some who don't. That'll be that'll be the way I summarize. OK, so I'm going to let Aseel take the floor. Thank you so much for this fascinating talk. I wanted to share an example of a positive example of recruiting community members to be there for those who are dying during the pandemic. In Colorado, we started a grass root group. And there was many of us in the field who were struggling with the fact of having patients either talk with their family members via Zoom or not even have anyone to be there for them. So a beautiful concept was born by one of our colleagues. She's a registered nurse called Peggy Bouddai. And she came up with the concept of the hug tunnel. And this was so amazing that basically we had to turn down volunteers who couldn't be there. And the idea or the concept of it is that you have this plastic piece that separates you from patients, especially who are dying and they're in long-term care facilities. And if they are able to get to that area close to the front door where they can just basically stand still and the volunteer put their hands in a, it's a hug tunnel. So you're covered by plastic, but you extend your arms and you hug the person, whether this was a family member who took advantage of this concept or community members. It was overwhelming and heartwarming to see how many people signed up. And we had to turn people away, but I'm wondering if there are similar concepts that are out there to help recruit community members to be there for those, especially that patient of yours who doesn't, who thinks that he's a difficult person and cannot find friends or somebody that would care for him towards the end of his life. How can we develop ways of recruiting community members? Yeah, that is a great question. So I have another project going on in New York City, which is they're a group of us who are really interested in this question. So this isn't so much what can ethics do or what can the hospital do, but what can communities do? So they're a group of us outside of the hospital. I'm the only physician, there's a death doula and there are people who work in clergy and nonprofit. Anyway, there's this little team of us and we're starting to imagine what it would be like to make it possible city-wide because New York City is so huge, we would try to break the city up into geographical areas, parishes, if you will, to use the old religious word, but we would, in a sense, the idea is to try to pair those who are lonely and dying with volunteers from their neighborhood. So this is a project in its infancy, but I think there are a lot of people who recognize that this is such a need. Dr. Vivek Murthy, who is our surgeon general, he's written a whole book on loneliness and loneliness is not just a problem among the dying, it's also a problem among the living, but certainly those of us who are connected with healthcare know that it's horrible to have patients die alone. So to try to, I think exactly as you said, Aseel, that's what our project in its infancy is striving to do is to start thinking of ways we can connect people. There are buddy systems right there, buddy systems where you pair kind of seniors with younger or more perhaps able-bodied individuals to kind of befriend them, but this would be, we're imagining it specifically for people who are closer to the end of their lives and in need of companionship. So I don't know again if that'll turn into anything, but I'm with you. I've never heard of the hug tunnel, so thank you for sharing that. I've definitely learned something new and it's interesting. It isn't, I'll also say as a primary care doctor, I have a reasonable number of patients who I, they have no need to come see me, but they come anyway because they, especially if they're on their own and no family members, no partner, they will come and I might be the only hand that they hold, right? The only hug that they get all month and they come again the next month and I give them another hug and hold their hand and chat because I think there are a lot of people who are really desperate for touch. We're relational creatures and we need, we need to be holding one another's hands. I mean, there's, those of us who are in relationships or have kids that are always in our business forget that people who have no one are just so desperate for someone to hold their hand. So, yeah, figuring out ways to do that is a very, very worthy goal. Thank you, Pat. Steve, I'm gonna let you take the floor. You're muted, Dr. Meredith. Thank you. I still do that even after two years of Zooming. So thank you, Lydia. That was a very interesting, beautiful talk and I have a lot of comments about it. Actually, this is more a comment than a question but just I wanted to say about, I've been recently reviewing Lucretius on the nature of things and he was an Epicurean, a devotee of Epicurus. He believed in seeking Adaraxia which is kind of an indifference towards death. Now, I bring that up for a few reasons. First of all, it shows that this concern about the art of dying way precedes monotheism and certainly Christianity. And it's found even among the Romans and the Greeks and the rival philosophy, Stoicism aimed for apathia which is more a lack of suffering about death. The reason I bring up those two to contrast is that one, the Epicureans were non-religious and the Stoics were religious. Now, final comment to make about that and then I'll shut up is that people have puzzled for a long time about the ending of Lucretius's poem because where it ends is he revisits the plague of Athens in 430 BC. And what many people have tried to figure out is first of all, did he finish the book or did he leave it unfinished because there's such a contrast between his philosophy which claims to have an answer to how to deal with the problem of death. Versus what he shows at the end which is people dying in misery no comfort about death whatsoever. It's very striking. So I guess this is to say you have your work cut out for you. This is an age old maybe intractable problem and that's all I have to say. Well, so Dr. Meredith taught me biochemistry and actually a lot of things and so I'm always a little nervous when you raise your hand. Don't be. And I still can't call you by your first name because of that. But I will say that one of the critiques of my work is that it starts in the late Middle Ages and is not comprehensive enough or global enough or multicultural enough. I just read about the R's more handy. I thought it was a compelling model and I thought why can't we try to think about what a similar handbook would look like? That's all. I'm not nearly as well read as Dr. Meredith or probably most of you on this call in terms of history of all the different approaches to dying but you're right and I'll just underscore your point which is that these questions go back to the beginning of humanity. People have wanted to know how to die well and so yeah, whether Lucretius or even earlier the questions have been on the table. But I think my point just to spell it out is just that I don't know how much of the anxiety about death really relates to the technology that we've thrown at death. It way precedes any of that. Yeah, well, so that's an interesting question. I mean, I think the technology is certainly complicated the conversation but so there's a wide variety of, you know, I've probably given like 80 talks on my book in the last year and a half. There's a wide variety of responses to the question of death anxiety. I think that death anxiety is a real thing for many people but it isn't for everybody. People have all different kinds of anxieties. Interestingly, it's interesting to me. So personally speaking, death anxiety has never never been something that ranks high on my list. I have other anxieties I don't need to share but then there are other people who are just plagued by death. Someone said to me the other day, she said, ever since a close friend died, I cannot stop reading obituaries and obsessing over how I'm going to die and I have young kids, she said. And I don't, you know, I don't know. So my point is that different people approach the question of a fear of death and death anxiety differently. But it's very, very, very strong for some people. Yes. Jay, I'm gonna just flip it around for a second because Darlene emailed me. So I'm gonna let her go and then I'll have you follow. Unmute yourself, Darlene. Great. Thank you very much. I'll just take a quick minute. I greatly enjoy this session today. Thank you. I'm an IPF patient whose husband passed away from IPF in 2003 and I was discovered with it in 2019, not first degree relatives and had to face the fact that my journey was gonna take a turn. And my biggest concern as an individual is, I'd like to die with grace. And so my faith helps me a great deal but the concern was more for the anxiety, not for myself. I'm 82 this week. So I'm not too concerned about the length of my life but I am concerned about the anxiety for those I'm leaving behind. And so decided that I had to start practicing like anything in life, a fire drill or whatever, I had to start practicing how I was gonna die and my communication skills. So I have conversations with my children who are in their 50s and 60s and my adult grandchildren about things I like or wanna do or remember when I'm gone, remember this or remember I always told you or whatever. So we're having these conversations to help prepare them. I probably have another, maybe a year or so and I'm good with that. Sometimes I kick the wall but most of the times it's okay. And I try to stay very active as a volunteer in the Pulmonary Fibrosis Foundation and being an ambassador there giving me volunteer activities. It's been wonderful. So I appreciate what you're saying and I particularly love the virtue approach. I'm gonna get your book, I'm gonna read it and I'm gonna read this other one from the Civil War. I think it's wonderful. But thank you so much and for allowing me to come in as a non-professional to be able to participate in this event which chose me this seminar and I'm thrilled. So thank you. Well, thank you Darlene and happy birthday to you. 82 is, that's a big deal. So yeah, I will just say very briefly I grew up in a home where talk of death was very common and not, well, I wouldn't say in a morbid sort of way but my grandfather was a bomber pilot in World War II. He was shot, well, he was, his plane malfunctioned during flight school. So he crashed once his flight instructor was beheaded and then he was shot down during the war and taken as a prisoner of war to the prison camp about which they filmed the Great Escape. I don't know if any of you have seen that film and he was there after the Great Escape. So it was particularly severe and then forced marches during the coldest winter on record in that part of the world. At any rate, he survived all that and lived to age 95 but he talked about death regularly in the home. Sometimes jokingly, he was very much a jokester but it was also just a part of the conversation that we're all mortal. I almost died when I was 22 he would say and I'm amazed that I'm still here for 20 years. We kept thinking he was gonna die. Everybody would fly back every year for the holidays just because grandpa might not make it next year. For 20 years he kept making it but it was sort of very matter of fact. So I think what you've said about practicing in conversation with your family to help ease some of their maybe misgivings about knowing that you have a terminal diagnosis as it were. The truth is that all of us have terminal diagnoses. We're all terminal. And so we all kind of need to be practicing, rehearsing and that's really the spirit of the R's Moriendi is that we rehearse these things throughout our lives. We habituate to the virtues so that in the end, we die better and that dying well is always within the context of community. One of the things I would strongly suggest the support groups I find for anybody no matter what their illness is, I think they're really good avenues. It's hard to get people to join them but when you join a support group you start learning from each other. And I think your program, your presentation is something that support groups would love to have because it helps people, it gives people tools and methods and new thoughts because you can't just sit around and think, okay, now my funeral is gonna be done. You've gotta have other thoughts and you've gotta have ways to get to that funeral. So I think if as you do your professional training and write your classroom documentation for training physicians and residents and that, but think about training support group leaders or organizations like the lung association or the cancer association, whomever it may be, pulmonary fibrosis association, give them tools that they can reach out and start training the people who are walking the journey because they're not, everybody in those support groups is not on the journey. I mean, they're on their terminal journey but they're not on that specific journey but they're there to help those who are traveling it. And so you can help them learn some of these things. It's really being bitter and mean and hateful at the end of your life is such an unkind thing to the rest of the world. And so we all need to find a way to approach it with and to be able to discuss frankly with the doctor, I just joined Pallity of Care, which I recognize a bit difference between that and hospice but it's an enhanced level of care. But that was a decision that I had to really think about. And so these are the things I think you can help us do. So when you finish or you won't finish because you have an unbelievable task but as you progress in your trainings, please consider the volunteers and the people who are the patients also need that same training. Maybe just in a different format. Thank you very much. Thank you. Darlene, that was a really good comment about the value of support groups. I'm glad you did that. I think we'll close out today's session with Jay. Take it away, Jay. Thanks, Lydia, lovely presentation. Good to see you. I wonder if you could just briefly offer a few words for how we might apply these lessons to children or adults with limited cognitive capacity for people who have limited abilities to prepare for their death through the manner in which they live their life. Thanks. Yeah, thanks, Jay. Nice to see you too. So with regard to children, this has to be part of the conversation with children. It has to be part of the conversation with children. So during the first wave of COVID, nobody knew what was going on. I live in a tiny New York City apartment with my spouse and two kids. And frankly, none of us really knew if we were gonna take COVID home, who would die. So we started having conversations regularly in the home about the fact that many people were dying from COVID. We didn't know if mommy and daddy and the girls would make it through to the other side. We needed it was high energy, high stress, having everybody home on Zoom school. We didn't know what the future would hold, but we also knew that we couldn't afford to waste energy fighting today, right? And I have girls and they're twins and there was a lot of fighting during those early days of COVID. There's always fighting. There was a lot of fighting during those early days of COVID. And our refrain, my husband was on board, kept being, guys, we don't know how many days we have together. One of us could die. And if it's not COVID, it could be something else. We said that so often to our girls. Now my girls, like they beat me to the punchline now, but it's a part of the conversation. Not to be morbid, but to keep the reality and focus that we are, we're human, we're limited, we're finite creatures. So kids can handle it. Kids get death better than adults do. Take your kids to funerals, get kids to as many things. They need to be part of it. They understand it. They kill a fly, the fly is dead, they get it. We're the ones who try to hide the dead thing, but not kids, kids understand it. With folks who have impaired ability to do the work of preparing for death, and this not just people who've waited too long and now are lost consciousness, but people who throughout their lives might not have this ability. This is exactly why the art of dying well was meant to be practiced and rehearsed within the context of a community. Because the community always bears up its weakest members, a strong, a functioning community should, right? So no, the community is always as weak as its weakest and as strong as they bring up the weakest, right? So if the community is functioning well and thriving, then the community is working to support the weakest. Now that might mean that the person with cognitive disabilities or otherwise can't of his or her own accord contribute. And that's fine, but that doesn't mean that the family or the community doesn't do that work. So what would that mean? Well, again, this is kind of culturally specific. So some of it, there's that practical healthcare piece in conversation with the doctors and the family. How much medicalization do we want? That's the conversation that needs to be had. But then there's the culturally specific pieces, which is what does it mean to prepare for death within your own context? Is there music? Are there prayers? Are there poems? What does that mean? And these are things, going back to the earliest iterations of the arts more Andy, there was this idea that the dying person was the central actor in a great drama and that all of the community members played supporting roles. If you, since this is the history, history medicine series, you know, Philippe Aries, the Frenchman who wrote the tome, the huge book on death, he talks about this concept. Every member of the community was a supporting actor in the great drama. The central actor was the dying person himself or herself. But also all of the supporting actors were in a sense an understudy for the lead role. Why? Because you have to prepare, you have to be the understudy for when you yourself will die. So if the dying person is incapacitated for whatever reason, the community still is rehearsing for their own deaths as they rehearse on behalf of the one who is dying. So I'll leave it at that, but it probably has to do with what brings meaning to you and your particular cultural context, but often prayers, readings, music, that sort of thing. Anyway, I wanna just once again thank Lydia for a terrific lecture and a wonderful way to end the 2021 year. We all really appreciate it, but I wanted to give you a few minutes to get some water before you start the 130 session and just thank you so much for coming here. We look forward at some point to seeing you in person. So thank you so much. Thanks so much. It's a pleasure to be with you.